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stroke-linecap="round" style="fill:#FFF" d="m320,350a153,153 0 1,0-2,2l170,170m-91-117 110,110-26,26-110-110"></path></svg></a><a id="jr-fip-done" class="wsprkl btn" title="Dismiss find">✘</a></nav><nav id="jr-fip-info-p"><a id="jr-fip-prev" class="wsprkl btn" title="Jump to previuos match">◀</a><button id="jr-fip-matches">no matches yet</button><a id="jr-fip-next" class="wsprkl btn" title="Jump to next match">▶</a></nav></nav></div><div id="jr-epub-interstitial" class="hidden"></div><div id="jr-content"><article data-type="main"><div class="main-content lit-style"><div class="fm-sec bkr_bottom_sep"><div class="bkr_thumb"><a href="https://www.nice.org.uk" title="National Institute for Health and Care Excellence (NICE)" class="img_link icnblk_img" ref="pagearea=logo&targetsite=external&targetcat=link&targettype=publisher"><img class="source-thumb" src="/corehtml/pmc/pmcgifs/bookshelf/thumbs/th-niceng219er12-lrg.png" alt="Cover of Evidence review for optimum frequency of monitoring" /></a></div><div class="bkr_bib"><h1 id="_NBK586317_"><span itemprop="name">Evidence review for optimum frequency of monitoring</span></h1><div class="subtitle">Gout: diagnosis and management</div><p><b>Evidence review L</b></p><p><i>NICE Guideline, No. 219</i></p><div class="half_rhythm">London: <a href="https://www.nice.org.uk" ref="pagearea=meta&targetsite=external&targetcat=link&targettype=publisher"><span itemprop="publisher">National Institute for Health and Care Excellence (NICE)</span></a>; <span itemprop="datePublished">2022 Jun</span>.<div class="small">ISBN-13: <span itemprop="isbn">978-1-4731-4603-7</span></div></div><div><a href="/books/about/copyright/">Copyright</a> © NICE 2022.</div></div><div class="bkr_clear"></div></div><div id="niceng219er12.s1"><h2 id="_niceng219er12_s1_">1. The optimum frequency of serum urate level monitoring for people continuing on urate-lowering therapies for gout</h2><div id="niceng219er12.s1.1"><h3>1.1. Review question: What is the optimum frequency of serum urate level monitoring for people continuing on urate-lowering therapies for gout?</h3><div id="niceng219er12.s1.1.1"><h4>1.1.1. Introduction</h4><p>Urate-lowering therapies for gout are long-term medications, often taken lifelong. With any treatment involving medication there is a need to monitor it to ensure it remains safe and effective at the prescribed dose. In gout monitoring is via measuring serum urate level to ensure it is within the targeted range. This is important because unless the serum urate is within the targeted range the urate lowering therapy will not be effective. For people who have reached therapeutic range good practice is to continue monitoring to check adherence and avoiding potential adverse effects for long-term treatment. However current practice is highly variable with many people only receiving serum urate monitoring <i>ad hoc</i> after a gout flare.</p><p>This aim of this review is to evaluate the optimum frequency of monitoring people on urate lowering therapy who have achieved serum urate level target.</p></div><div id="niceng219er12.s1.1.2"><h4>1.1.2. Summary of the protocol</h4><p>For full details see the review protocol in <a href="#niceng219er12.appa">Appendix A</a>.</p><div class="iconblock whole_rhythm clearfix ten_col table-wrap" id="figniceng219er12tab1"><a href="/books/NBK586317/table/niceng219er12.tab1/?report=objectonly" target="object" title="Table 1" class="img_link icnblk_img figpopup" rid-figpopup="figniceng219er12tab1" rid-ob="figobniceng219er12tab1"><img class="small-thumb" src="/books/NBK586317/table/niceng219er12.tab1/?report=thumb" src-large="/books/NBK586317/table/niceng219er12.tab1/?report=previmg" alt="Table 1. PICO characteristics of review question." /></a><div class="icnblk_cntnt"><h4 id="niceng219er12.tab1"><a href="/books/NBK586317/table/niceng219er12.tab1/?report=objectonly" target="object" rid-ob="figobniceng219er12tab1">Table 1</a></h4><p class="float-caption no_bottom_margin">PICO characteristics of review question. </p></div></div></div><div id="niceng219er12.s1.1.3"><h4>1.1.3. Methods and process</h4><p>This evidence review was developed using the methods and process described in <a href="https://www.nice.org.uk/process/pmg20/chapter/introduction-and-overview" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">Developing NICE guidelines: the manual</a>. Methods specific to this review question are described in the review protocol in <a href="#niceng219er12.appa">Appendix A</a> and the methods document.</p><p>Declarations of interest were recorded according to <a href="https://www.nice.org.uk/about/who-we-are/policies-and-procedures" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">NICE’s conflicts of interest policy</a>.</p></div><div id="niceng219er12.s1.1.4"><h4>1.1.4. Effectiveness evidence</h4><div id="niceng219er12.s1.1.4.1"><h5>1.1.4.1. Included studies</h5><p>No relevant clinical studies comparing different monitoring strategies were identified.</p><p>See also the study selection flow chart in <a href="#niceng219er12.appc">Appendix C</a>.</p></div><div id="niceng219er12.s1.1.4.2"><h5>1.1.4.2. Excluded studies</h5><p>See the excluded studies list in <a href="#niceng219er12.appj">Appendix J</a>.</p></div></div><div id="niceng219er12.s1.1.5"><h4>1.1.5. Summary of studies included in the effectiveness evidence</h4><p>No evidence was identified for this review.</p></div><div id="niceng219er12.s1.1.6"><h4>1.1.6. Summary of the effectiveness evidence</h4><p>No evidence was identified for this review.</p></div><div id="niceng219er12.s1.1.7"><h4>1.1.7. Economic evidence</h4><div id="niceng219er12.s1.1.7.1"><h5>1.1.7.1. Included studies</h5><p>No health economic studies were included.</p></div><div id="niceng219er12.s1.1.7.2"><h5>1.1.7.2. Excluded studies</h5><p>Two economic studies relating to this review question were identified but were excluded due to a combination of limited applicability and methodological limitations <a class="bibr" href="#niceng219er12.ref8" rid="niceng219er12.ref8"><sup>8</sup></a><sup>,</sup>
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<a class="bibr" href="#niceng219er12.ref14" rid="niceng219er12.ref14"><sup>14</sup></a>. These are listed in <a href="#niceng219er12.appj">Appendix J</a>, with reasons for exclusion given.</p></div></div><div id="niceng219er12.s1.1.8"><h4>1.1.8. Economic model</h4><p>This topic was identified as medium – high modelling priority area but no clinical or economic evidence was identified for this review question. Subsequently, a costing analysis was undertaken to determine the number of flares which need to be avoided (per person per year) for the cost of annual monitoring to break even.</p><p>The costing analysis estimated the total cost of annual monitoring for people who have achieved target serum urate levels and the total cost of a gout flare. The total cost of monitoring was divided by the total cost of a gout flare to obtain a value for the number of flares avoided for annual monitoring to break even.</p><div id="niceng219er12.s1.1.8.1"><h5>The cost of annual monitoring</h5><p>The cost of annual monitoring was estimated for two patient populations:
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<ol><li class="half_rhythm"><div>People with gout with comorbidities</div></li><li class="half_rhythm"><div>People with gout without comorbidities</div></li></ol></p><p>Monitoring for people with gout once they have achieved target serum urate levels is relatively simple whereby a blood test is taken to measure serum urate levels. If serum urate levels are above target, ULT will be adjusted until people reobtain target levels. ULT treatment for people with gout with a number of comorbidities is the same for people without comorbidities, with the exception of people with CKD where lower doses of allopurinol are prescribed. The committee noted it is very common for people with CKD to have gout, so clinicians are well informed on how people with gout and CKD should be managed. In addition, people with more severe CKD are likely to be treated in secondary care and monitoring of serum urate levels can be conducted in an appointment visiting a rheumatologist.</p><p>The committee concluded the cost of monitoring for people without comorbidities would be more expensive as an additional appointment would be required for these group of people. Whereas monitoring for gout for people with comorbidities could be conducted alongside additional appointments people receive for other comorbidities.</p><p>The costs of monitoring for people with gout with comorbidities are presented in <a class="figpopup" href="/books/NBK586317/table/niceng219er12.tab2/?report=objectonly" target="object" rid-figpopup="figniceng219er12tab2" rid-ob="figobniceng219er12tab2">Table 2</a>.</p><div class="iconblock whole_rhythm clearfix ten_col table-wrap" id="figniceng219er12tab2"><a href="/books/NBK586317/table/niceng219er12.tab2/?report=objectonly" target="object" title="Table 2" class="img_link icnblk_img figpopup" rid-figpopup="figniceng219er12tab2" rid-ob="figobniceng219er12tab2"><img class="small-thumb" src="/books/NBK586317/table/niceng219er12.tab2/?report=thumb" src-large="/books/NBK586317/table/niceng219er12.tab2/?report=previmg" alt="Table 2. Cost of monitoring for people with comorbidities." /></a><div class="icnblk_cntnt"><h4 id="niceng219er12.tab2"><a href="/books/NBK586317/table/niceng219er12.tab2/?report=objectonly" target="object" rid-ob="figobniceng219er12tab2">Table 2</a></h4><p class="float-caption no_bottom_margin">Cost of monitoring for people with comorbidities. </p></div></div><p>The costs of monitoring for people with gout without comorbidities are presented in <a class="figpopup" href="/books/NBK586317/table/niceng219er12.tab3/?report=objectonly" target="object" rid-figpopup="figniceng219er12tab3" rid-ob="figobniceng219er12tab3">Table 3</a>.</p><div class="iconblock whole_rhythm clearfix ten_col table-wrap" id="figniceng219er12tab3"><a href="/books/NBK586317/table/niceng219er12.tab3/?report=objectonly" target="object" title="Table 3" class="img_link icnblk_img figpopup" rid-figpopup="figniceng219er12tab3" rid-ob="figobniceng219er12tab3"><img class="small-thumb" src="/books/NBK586317/table/niceng219er12.tab3/?report=thumb" src-large="/books/NBK586317/table/niceng219er12.tab3/?report=previmg" alt="Table 3. Cost of monitoring for people without comorbidities." /></a><div class="icnblk_cntnt"><h4 id="niceng219er12.tab3"><a href="/books/NBK586317/table/niceng219er12.tab3/?report=objectonly" target="object" rid-ob="figobniceng219er12tab3">Table 3</a></h4><p class="float-caption no_bottom_margin">Cost of monitoring for people without comorbidities. </p></div></div><p>These costs were multiplied by the proportion of people with gout with and without comorbidities provided by Guthrie et al.<a class="bibr" href="#niceng219er12.ref6" rid="niceng219er12.ref6"><sup>6</sup></a>. The proportion of people with gout with comorbidities was 86.90% and the proportion of people without comorbidities was 13.10%. This resulted in a total cost for annual monitoring of £34.14.</p></div><div id="niceng219er12.s1.1.8.2"><h5>The cost of a gout flare</h5><p>The cost of a gout flare was estimated for a total of eight different scenarios and presented in <a class="figpopup" href="/books/NBK586317/table/niceng219er12.tab4/?report=objectonly" target="object" rid-figpopup="figniceng219er12tab4" rid-ob="figobniceng219er12tab4">Table 4</a>. The methodology for obtaining the cost of a gout flare can be found in <a href="https://guidelines.rcplondon.ac.uk/Gout/04%20Development/02%20Evidence%20reviews/G_Evidence%20review_urate%20lowering%20therapies%20for%20the%20long-term%20management%20of%20gout%204.2-4.4.docx" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">Evidence review G</a>.</p><div class="iconblock whole_rhythm clearfix ten_col table-wrap" id="figniceng219er12tab4"><a href="/books/NBK586317/table/niceng219er12.tab4/?report=objectonly" target="object" title="Table 4" class="img_link icnblk_img figpopup" rid-figpopup="figniceng219er12tab4" rid-ob="figobniceng219er12tab4"><img class="small-thumb" src="/books/NBK586317/table/niceng219er12.tab4/?report=thumb" src-large="/books/NBK586317/table/niceng219er12.tab4/?report=previmg" alt="Table 4. Cost of a gout flare." /></a><div class="icnblk_cntnt"><h4 id="niceng219er12.tab4"><a href="/books/NBK586317/table/niceng219er12.tab4/?report=objectonly" target="object" rid-ob="figobniceng219er12tab4">Table 4</a></h4><p class="float-caption no_bottom_margin">Cost of a gout flare. </p></div></div></div><div id="niceng219er12.s1.1.8.3"><h5>Results</h5><p>The number of gout flares required for annual monitoring to break even was estimated by dividing the cost of a gout flare by the cost of annual monitoring. The results of the costing analysis are presented in <a class="figpopup" href="/books/NBK586317/table/niceng219er12.tab5/?report=objectonly" target="object" rid-figpopup="figniceng219er12tab5" rid-ob="figobniceng219er12tab5">Table 5</a>.</p><div class="iconblock whole_rhythm clearfix ten_col table-wrap" id="figniceng219er12tab5"><a href="/books/NBK586317/table/niceng219er12.tab5/?report=objectonly" target="object" title="Table 5" class="img_link icnblk_img figpopup" rid-figpopup="figniceng219er12tab5" rid-ob="figobniceng219er12tab5"><img class="small-thumb" src="/books/NBK586317/table/niceng219er12.tab5/?report=thumb" src-large="/books/NBK586317/table/niceng219er12.tab5/?report=previmg" alt="Table 5. Results for the number of gout flares required to be avoided per person for the cost of monitoring to break even." /></a><div class="icnblk_cntnt"><h4 id="niceng219er12.tab5"><a href="/books/NBK586317/table/niceng219er12.tab5/?report=objectonly" target="object" rid-ob="figobniceng219er12tab5">Table 5</a></h4><p class="float-caption no_bottom_margin">Results for the number of gout flares required to be avoided per person for the cost of monitoring to break even. </p></div></div><p>Based on the results of the eight scenarios the average number of flares which need to be avoided per person, per year, for annual monitoring to break even ranges from 0.61 – 1.26.</p></div></div><div id="niceng219er12.s1.1.9"><h4>1.1.9. Unit costs</h4><p>Relevant unit costs are provided below to aid consideration of cost effectiveness.</p><div class="iconblock whole_rhythm clearfix ten_col table-wrap" id="figniceng219er12tab6"><a href="/books/NBK586317/table/niceng219er12.tab6/?report=objectonly" target="object" title="Table 6" class="img_link icnblk_img figpopup" rid-figpopup="figniceng219er12tab6" rid-ob="figobniceng219er12tab6"><img class="small-thumb" src="/books/NBK586317/table/niceng219er12.tab6/?report=thumb" src-large="/books/NBK586317/table/niceng219er12.tab6/?report=previmg" alt="Table 6. Unit costs." /></a><div class="icnblk_cntnt"><h4 id="niceng219er12.tab6"><a href="/books/NBK586317/table/niceng219er12.tab6/?report=objectonly" target="object" rid-ob="figobniceng219er12tab6">Table 6</a></h4><p class="float-caption no_bottom_margin">Unit costs. </p></div></div></div><div id="niceng219er12.s1.1.10"><h4>1.1.10. Evidence statements</h4><div id="niceng219er12.s1.1.10.1"><h5>Economic</h5><ul><li class="half_rhythm"><div>No relevant economic evaluations were identified.</div></li></ul></div></div><div id="niceng219er12.s1.1.11"><h4>1.1.11. The committee’s discussion and interpretation of the evidence</h4><div id="niceng219er12.s1.1.11.1"><h5>1.1.11.1. The outcomes that matter most</h5><p>The committee considered the following outcomes as important for decision making health-related quality of life, patient global assessment of treatment success, pain, joint swelling/joint inflammation, joint tenderness, serum urate level, frequency of flares, tophi, admission (hospital and A&E/urgent care) and GP visits.</p><p>Studies that reported serum urate level outcomes would be of particular interest because changes to levels after the target had been reached would require the prescriber to intervene to bring the serum urate level back within the target range. Studies that reported changes at different timepoints would guide the committee in their recommendation on what the frequency of monitoring serum urate should be.</p><p>The committee decided to combine joint swelling and joint inflammation as they agreed that these outcomes are synonymous for people with gout. To help guide recommendations the committee were interested in the different frequencies of monitoring reported and decided to categorise time points reported in the included studies by short-term (up to 6 months), medium-term (6 to 12 months) and long-term (more than 12 months).</p></div><div id="niceng219er12.s1.1.11.2"><h5>1.1.11.2. The quality of the evidence</h5><p>No evidence was identified. The committee decided to make a consensus recommendation based on their clinical experience.</p><p>The committee noted the recommendation made for a treat-to-target ULT strategy which would indicate a requirement to monitor a person’s serum urate levels. As no evidence was found and annual monitoring would have a resource impact because it would be a change in practice the committee decided to make a research recommendation on the optimum frequency of serum urate level monitoring in people who have achieved target serum urate level.</p></div><div id="niceng219er12.s1.1.11.3"><h5>1.1.11.3. Benefits and harms</h5><p>The committee agreed that one of the reasons for continuing to monitor a person’s serum urate level when they have achieved the target serum urate level is to detect any subsequent rises in the level, which can occur with age, new medications (e.g. diuretics), decline in renal function, or as a result of changes in lifestyle. Rises in the serum urate level above target would necessitate more intensive ULT to lower the level again. The committee noted that changes in serum urate level occurs quickly usually within months, therefore regular monitoring would identify changes early and facilitate early intervention. Adherence to ULT was discussed, and the committee noted that people tend to stop treatment if they feel better, however continuing ULT as prescribed is important as serum urate levels rise quickly after a person stops taking ULT, leading to a recurrence of symptomatic gout.</p><p>The committee discussed that in current practice the frequency and delivery of serum urate level monitoring is highly variable, and decisions are usually based on individual factors after discussion with the patient. More often, visits by patients to clinical practice are triggered by gout flares and only then would a health professional measure a person’s serum urate level. However, the committee were in agreement that this was not sufficient as the goal of monitoring is to maintain the person at the target level and prevent future gout flares rather than flare management. The committee agreed based on their experience that annual monitoring of serum urate levels would be an appropriate frequency as this would provide enough time to see the result of prescribing urate lowering therapy on serum urate levels and then to adjust treatment as required. The committee acknowledged this would also reflect the British Society of Rheumatology’s guidance to carry out annual serum urate level checks. The committee agreed that monitoring is also an opportunity to review treatment, adherence and address any concerns the person may have. NICE guidelines on medicine adherence (CG76) recommend regular review of medicines and at least annual review is accepted as good practice. The data available from the multimorbidity and clinical guidelines research project<a class="bibr" href="#niceng219er12.ref6" rid="niceng219er12.ref6"><sup>6</sup></a> on the prevalence of comorbidities in people with gout indicated that the large majority (83%) of people with gout have comorbidities. They would require monitoring for these other conditions and any medications required to treat them, therefore, the committee concluded monitoring of ULT could be done as part of another appointment and not involve extra appointments. NICE guidelines on CKD recommend review (including blood tests) annually or more often. The monitoring of urate level annually and the management of ULT is therefore likely to be included among review of other medicines and treatments.</p></div><div id="niceng219er12.s1.1.11.4"><h5>1.1.11.4. Cost effectiveness and resource use</h5><p>No published health economic evidence was identified for this review. However, a costing analysis was conducted to determine the number of flares needed to be avoided per person over a period of one year for annual monitoring to break even to aid consideration of cost-effectiveness.</p><p>The costing analysis indicated the average number of flares which need to be avoided per person for annual monitoring to break even ranged from 0.61 – 1.26 dependent on the cost of a gout flare which was used in the analysis. The results of the analysis were sensitive to the proportion of people receiving hospital treatment for their gout flare. When 1% of people were treated in hospital the average number of flares needed to be avoided per person for annual monitoring to break even ranged from 1.12 – 1.26. However, when 5% of people received treatment in hospital for their gout flare the average number of flares needed to be avoided per person for annual monitoring to break even ranged from 0.61 – 0.65.</p><p>The committee acknowledged a number of assumptions were required as part of the costing analysis. For the cost of monitoring, health care professional time was based on committee opinion for the cost of a gout flare, the proportion of people being treated in each health care setting, the proportion of people incurring costs associated with hospital treatment for a gout flare, and health care professional time was also based on committee opinion. The uncertainty surrounding the proportion of people being treated in each health care setting was partly overcome by the eight scenarios analyses run where the proportion of people treated in each health care setting was varied. The committee accepted uncertainty could not be reduced further due to lack evidence and acknowledged this was a limitation of the analysis.</p><p>In general, the committee noted there is no specific data available on the number flares prevented as a result of monitoring. In addition, once people have achieved target serum urate levels monitoring is very rarely conducted in clinical practice. Therefore, the committee acknowledged it was challenging to estimate how many flares would be avoided as a result of annual monitoring.</p><p>The committee did however note the well-established link between target serum urate levels above 360µmol/L and increased number of gout flares (compared to people with a serum urate level of <360µmol/L) and acknowledged that people who receive monitoring are more likely to remain at target serum urate levels. This is because having serum urate levels measured more frequently than currently observed in clinical practice allows for ULT to be adjusted accordingly if required. Currently people may not realise their serum urate levels have deviated from target until they experience a gout flare. If, as a result of annual monitoring, a change in serum urate level is detected before a gout flare occurs this may mean serum urate levels have not deviated significantly above target levels, which may make it cheaper and less resource intensive to reobtain target serum urate levels. For example, someone may require a higher dose of allopurinol to reobtain target serum urate levels.</p><p>The committee also noted people who receive monitoring may be more likely to adhere to their ULT. Due to a lack of understanding that ULTs are a lifelong medication, adherence can be a problem whereby once people are symptom free via treatment, they may believe they no longer to need to take their ULT. In addition, adherence to allopurinol can be worse compared to febuxostat. The committee acknowledged there are number of reasons this may be the case, for example, as result of a potential higher pill burden associated with allopurinol. But also noted this may be because allopurinol is prescribed a first-line treatment option. If people are switched to febuxostat as their second-line treatment option adherence may be better due to a lack of additional treatment options. Overall, employing monitoring for people with gout may help people understand the importance of taking their ULT. The committee also discussed that the lack of monitoring currently provided in clinical practice can diminish people’s perceptions of the severity of gout, whereby people with gout may believe their condition is not serious because monitoring is not provided.</p><p>The committee recalled the proportion of people experiencing gout flares in the Doherty treat-to-target trial<a class="bibr" href="#niceng219er12.ref4" rid="niceng219er12.ref4"><sup>4</sup></a> to make inferences about how many flares may be avoided as a result of annual monitoring. In Doherty, both the nurse-led and usual care arms experienced similar levels of flares at baseline: 79.92% and 79.77% respectively experienced two or more flares and 38.04% and 35.11% respectively experienced four or more flares. At 2 years 8.00% and 24.29% of people in the nurse-led and usual care arms respectively experienced two or more flares. Furthermore, 1.15% and 12.39% of people in the nurse-led and usual care arms respectively experienced four or more flares. Of note at 2 years, 94.88% and 88.05% of people in the nurse-led arm achieved a target serum urate level of <360<i>μ</i>mol/and <300<i>μ</i>mol/L respectively. Conversely in the usual care arm, 29.71% and 17.46% of people achieved a target serum urate level of <360<i>μ</i>mol/L and <300<i>μ</i>mol/L respectively. The committee discussed that although this trial did not provide data on the effects of monitoring, it does illustrate the relationship between target serum urate levels and the number of flares, whereby people not achieving target serum urate levels experience a greater number of flares.</p><p>The committee acknowledged estimating the number of flares avoided as a result of annual monitoring was uncertain. The committee discussed the results and noted it was highly likely annual monitoring would break even or be cost saving when 5% of people with gout receive treatment for a gout flare in hospital (when the average number of flares needed to be avoided per person for annual monitoring to break even ranged from 0.61 – 0.65). The committee concluded it was likely annual monitoring would break even or be cost saving when 1% of people with gout receive treatment for a gout flare in hospital (when the average number of flares needed to be avoided per person for annual monitoring to break even ranged from 1.12 – 1.26). However, they acknowledged there was more uncertainty surrounding this due to a greater of number of flares needed to be avoided for annual monitoring to break even. Due to this uncertainty and the absence of clinical evidence, the committee agreed to make a consider recommendation for annual monitoring to be conducted once people have achieved target serum urate levels.</p><p>There is large variation in clinical practice as to how frequently – if at all – monitoring is conducted to measure a person’s serum urate level once target serum urate levels have been achieved. In general, the purpose of monitoring is to determine if people are on the correct dose of ULT. Monitoring will involve a clinical professional conducting a blood test to measure a person’s serum urate level and ensure serum urate levels are below target. If serum urate levels are above target, the appropriate course of action will be taken (for example, up titration of ULT) by a clinical professional to ensure target levels are subsequently achieved. Because monitoring is rarely conducted in clinical practice this recommendation will likely have an impact on resources as it is a change in practice for a large proportion of the gout population. The impact on resources will be seen in the form of increased staff time and serum urate level testing. As the number of people receiving ULT is expected to increase as a result of the recommendations made in this guideline, this will also increase the number of people being monitored once people achieve target serum urate levels.</p></div></div><div id="niceng219er12.s1.1.12"><h4>1.1.12. Recommendations supported by this evidence review</h4><p>This evidence review supports recommendations 1.5.15 and the research recommendation on, the optimum frequency of serum urate level monitoring in people with gout when target serum urate level is reached.</p></div><div id="niceng219er12.rl.r1"><h4>1.1.13. References</h4><dl class="temp-labeled-list"><dl class="bkr_refwrap"><dt>1.</dt><dd><div class="bk_ref" id="niceng219er12.ref1">Alvarado-de la Barrera
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C, Lopez-Lopez
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CO, Alvarez-Hernandez
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E, Pelaez-Ballestas
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I, Gomez-Ruiz
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C, Burgos-Vargas
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R
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et al
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Are target urate and remission possible in severe gout? A five-year cohort study. Journal of Rheumatology. 2020; 47(1):132–139 [<a href="https://pubmed.ncbi.nlm.nih.gov/31043541" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 31043541</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>2.</dt><dd><div class="bk_ref" id="niceng219er12.ref2">Bai
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X, Sun
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M, He
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Y, Liu
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R, Cui
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L, Wang
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C
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et al
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Serum CA72–4 is specifically elevated in gout patients and predicts flares. Rheumatology. 2020; 59(10):2872–2880 [<a href="/pmc/articles/PMC7516098/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC7516098</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/32087013" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 32087013</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>3.</dt><dd><div class="bk_ref" id="niceng219er12.ref3">Beecham
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J, Curtis
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L. Unit costs of health and social care
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2020. Canterbury. Personal Social Services Research Unit University of Kent, 2020. Available from: <a href="https://www.pssru.ac.uk/project-pages/unit-costs/" ref="pagearea=cite-ref&targetsite=external&targetcat=link&targettype=uri">https://www<wbr style="display:inline-block"></wbr>​.pssru.ac<wbr style="display:inline-block"></wbr>​.uk/project-pages/unit-costs/</a></div></dd></dl><dl class="bkr_refwrap"><dt>4.</dt><dd><div class="bk_ref" id="niceng219er12.ref4">Doherty
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M, Jenkins
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W, Richardson
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H, Sarmanova
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A, Abhishek
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A, Ashton
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et al
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Efficacy and cost-effectiveness of nurse-led care involving education and engagement of patients and a treat-to-target urate-lowering strategy versus usual care for gout: a randomised controlled trial. Lancet. 2018; 392(10156):1403–1412 [<a href="/pmc/articles/PMC6196879/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC6196879</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/30343856" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 30343856</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>5.</dt><dd><div class="bk_ref" id="niceng219er12.ref5">Edwards
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NL, Sundy
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JS, Forsythe
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A, Blume
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S, Pan
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F, Becker
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MA. Work productivity loss due to flares in patients with chronic gout refractory to conventional therapy. Journal of Medical Economics. 2011; 14(1):10–15 [<a href="https://pubmed.ncbi.nlm.nih.gov/21138339" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 21138339</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>6.</dt><dd><div class="bk_ref" id="niceng219er12.ref6">Guthrie
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B. Multimorbidity and clinical guidelines: using epidemiology to quantify the applicability of trial evidence to inform guideline development [unpublished]. University of Edinburgh.</div></dd></dl><dl class="bkr_refwrap"><dt>7.</dt><dd><div class="bk_ref" id="niceng219er12.ref7">Harrold
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LR, Andrade
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SE, Briesacher
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B, Raebel
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MA, Fouayzi
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H, Yood
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RA
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et al
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The dynamics of chronic gout treatment: medication gaps and return to therapy. American Journal of Medicine. 2010; 123(1):54–59 [<a href="/pmc/articles/PMC2813203/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC2813203</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/20102992" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 20102992</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>8.</dt><dd><div class="bk_ref" id="niceng219er12.ref8">Hill-McManus
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D, Marshall
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S, Soto
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E, Lane
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S, Hughes
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D. Impact of non-adherence and flare resolution on the cost-effectiveness of treatments for gout: Application of a linked pharmacometric/pharmacoeconomic model. Value in Health. 2018; 21(12):1373–1381 [<a href="https://pubmed.ncbi.nlm.nih.gov/30502780" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 30502780</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>9.</dt><dd><div class="bk_ref" id="niceng219er12.ref9">McLachlan
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A, Kerr
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A, Lee
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M, Dalbeth
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N. Nurse-led cardiovascular disease risk management intervention for patients with gout. European Journal of Cardiovascular Nursing. 2011; 10(2):94–100 [<a href="https://pubmed.ncbi.nlm.nih.gov/20605527" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 20605527</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>10.</dt><dd><div class="bk_ref" id="niceng219er12.ref10">National Institute for Health and Care Excellence. Developing NICE guidelines: the manual [updated October 2020]. London. National Institute for Health and Care Excellence, 2014. Available from: <a href="http://www.nice.org.uk/article/PMG20/chapter/1%20Introduction%20and%20overview" ref="pagearea=cite-ref&targetsite=external&targetcat=link&targettype=uri">http://www<wbr style="display:inline-block"></wbr>​.nice.org.uk<wbr style="display:inline-block"></wbr>​/article/PMG20/chapter<wbr style="display:inline-block"></wbr>​/1%20Introduction%20and%20overview</a></div></dd></dl><dl class="bkr_refwrap"><dt>11.</dt><dd><div class="bk_ref" id="niceng219er12.ref11">NHS England and NHS Improvement. National Cost Collection Data Publication 2019–2020. London. 2020. Available from: <a href="https://www.england.nhs.uk/wp-content/uploads/2021/06/National-Cost-Collection-2019-20-Report-FINAL.pdf" ref="pagearea=cite-ref&targetsite=external&targetcat=link&targettype=uri">https://www<wbr style="display:inline-block"></wbr>​.england.nhs<wbr style="display:inline-block"></wbr>​.uk/wp-content/uploads<wbr style="display:inline-block"></wbr>​/2021/06/National-Cost-Collection-2019-20-Report-FINAL<wbr style="display:inline-block"></wbr>​.pdf</a></div></dd></dl><dl class="bkr_refwrap"><dt>12.</dt><dd><div class="bk_ref" id="niceng219er12.ref12">Perez-Ruiz
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F, Herrero-Beites
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AM, Carmona
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L. A two-stage approach to the treatment of hyperuricemia in gout: the “dirty dish” hypothesis. Arthritis and Rheumatism. 2011; 63(12):4002–4006 [<a href="https://pubmed.ncbi.nlm.nih.gov/21898351" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 21898351</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>13.</dt><dd><div class="bk_ref" id="niceng219er12.ref13">Raebel
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MA, McClure
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DL, Simon
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SR, Chan
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KA, Feldstein
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AC, Gunter
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MJ
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et al
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Frequency of serum creatinine monitoring during allopurinol therapy in ambulatory patients. Annals of Pharmacotherapy. 2006; 40(3):386–391 [<a href="https://pubmed.ncbi.nlm.nih.gov/16478808" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 16478808</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>14.</dt><dd><div class="bk_ref" id="niceng219er12.ref14">Robinson
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PC, Dalbeth
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N, Donovan
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P. The cost-effectiveness of biannual serum urate (su) monitoring after reaching target in gout: A health economic analysis comparing su monitoring. Journal of Rheumatology. 2018; 45(5):697–704 [<a href="https://pubmed.ncbi.nlm.nih.gov/29449500" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 29449500</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>15.</dt><dd><div class="bk_ref" id="niceng219er12.ref15">Shoji
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A, Yamanaka
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H, Kamatani
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N. A retrospective study of the relationship between serum urate level and recurrent attacks of gouty arthritis: evidence for reduction of recurrent gouty arthritis with antihyperuricemic therapy. Arthritis and Rheumatism. 2004; 51(3):321–325 [<a href="https://pubmed.ncbi.nlm.nih.gov/15188314" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 15188314</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>16.</dt><dd><div class="bk_ref" id="niceng219er12.ref16">Wall
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GC, Koenigsfeld
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CF, Hegge
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KA, Bottenberg
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MM. Adherence to treatment guidelines in two primary care populations with gout. Rheumatology International. 2010; 30(6):749–753 [<a href="https://pubmed.ncbi.nlm.nih.gov/19590874" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 19590874</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>17.</dt><dd><div class="bk_ref" id="niceng219er12.ref17">Yeo
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E, Palmer
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SC, Chapman
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PT, Frampton
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C, Stamp
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LK. Serum urate levels and therapy in adults treated with long-term dialysis: a retrospective cross-sectional study. Internal Medicine Journal. 2019; 49(7):838–842 [<a href="https://pubmed.ncbi.nlm.nih.gov/30426652" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 30426652</span></a>]</div></dd></dl></dl></div></div></div><div id="appendixesappgroup1"><h2 id="_appendixesappgroup1_">Appendices</h2><div id="niceng219er12.appa"><h3>Appendix A. Review protocols</h3><p id="niceng219er12.appa.et1"><a href="/books/NBK586317/bin/niceng219er12-appa-et1.pdf" class="bk_dwnld_icn bk_dwnld_pdf">Download PDF</a><span class="small"> (229K)</span></p></div><div id="niceng219er12.appb"><h3>Appendix B. Literature search strategies</h3><ul><li class="half_rhythm"><div>What is the optimum frequency of serum urate level monitoring for people continuing on urate-lowering therapies for gout?</div></li></ul><p>The literature searches for this review are detailed below and complied with the methodology outlined in Developing NICE guidelines: the manual.<a class="bibr" href="#niceng219er12.ref10" rid="niceng219er12.ref10"><sup>10</sup></a></p><p>For more information, please see the Methodology review published as part of the accompanying documents for this guideline.</p><p id="niceng219er12.appb.et1"><a href="/books/NBK586317/bin/niceng219er12-appb-et1.pdf" class="bk_dwnld_icn bk_dwnld_pdf">B.1. Clinical search literature search strategy</a><span class="small"> (PDF, 214K)</span></p><p id="niceng219er12.appb.et2"><a href="/books/NBK586317/bin/niceng219er12-appb-et2.pdf" class="bk_dwnld_icn bk_dwnld_pdf">B.2. Health Economics literature search strategy</a><span class="small"> (PDF, 175K)</span></p></div><div id="niceng219er12.appc"><h3>Appendix C. Effectiveness evidence study selection</h3><p id="niceng219er12.appc.et1"><a href="/books/NBK586317/bin/niceng219er12-appc-et1.pdf" class="bk_dwnld_icn bk_dwnld_pdf">Download PDF</a><span class="small"> (111K)</span></p></div><div id="niceng219er12.appd"><h3>Appendix D. Effectiveness evidence</h3><p>No studies were included.</p></div><div id="niceng219er12.appe"><h3>Appendix E. Forest plots</h3><p>No studies were included.</p></div><div id="niceng219er12.appf"><h3>Appendix F. GRADE tables</h3><p>No studies were included.</p></div><div id="niceng219er12.appg"><h3>Appendix G. Economic evidence study selection</h3><p id="niceng219er12.appg.et1"><a href="/books/NBK586317/bin/niceng219er12-appg-et1.pdf" class="bk_dwnld_icn bk_dwnld_pdf">Download PDF</a><span class="small"> (171K)</span></p></div><div id="niceng219er12.apph"><h3>Appendix H. Economic evidence tables</h3><p>None.</p></div><div id="niceng219er12.appi"><h3>Appendix I. Health economic model</h3><p>No original economic modelling was undertaken for this review question.</p></div><div id="niceng219er12.appj"><h3>Appendix J. Excluded studies</h3><div id="niceng219er12.appj.s1"><h4>Clinical studies</h4><div class="iconblock whole_rhythm clearfix ten_col table-wrap" id="figniceng219er12appjtab1"><a href="/books/NBK586317/table/niceng219er12.appj.tab1/?report=objectonly" target="object" title="Table 9" class="img_link icnblk_img figpopup" rid-figpopup="figniceng219er12appjtab1" rid-ob="figobniceng219er12appjtab1"><img class="small-thumb" src="/books/NBK586317/table/niceng219er12.appj.tab1/?report=thumb" src-large="/books/NBK586317/table/niceng219er12.appj.tab1/?report=previmg" alt="Table 9. Studies excluded from the clinical review." /></a><div class="icnblk_cntnt"><h4 id="niceng219er12.appj.tab1"><a href="/books/NBK586317/table/niceng219er12.appj.tab1/?report=objectonly" target="object" rid-ob="figobniceng219er12appjtab1">Table 9</a></h4><p class="float-caption no_bottom_margin">Studies excluded from the clinical review. </p></div></div></div><div id="niceng219er12.appj.s2"><h4>Health Economic studies</h4><p>Published health economic studies that met the inclusion criteria (relevant population, comparators, economic study design, published 2005 or later and not from non-OECD country or USA) but that were excluded following appraisal of applicability and methodological quality are listed below. See the health economic protocol for more details.</p><div class="iconblock whole_rhythm clearfix ten_col table-wrap" id="figniceng219er12appjtab2"><a href="/books/NBK586317/table/niceng219er12.appj.tab2/?report=objectonly" target="object" title="Table 10" class="img_link icnblk_img figpopup" rid-figpopup="figniceng219er12appjtab2" rid-ob="figobniceng219er12appjtab2"><img class="small-thumb" src="/books/NBK586317/table/niceng219er12.appj.tab2/?report=thumb" src-large="/books/NBK586317/table/niceng219er12.appj.tab2/?report=previmg" alt="Table 10. Studies excluded from the health economic review." /></a><div class="icnblk_cntnt"><h4 id="niceng219er12.appj.tab2"><a href="/books/NBK586317/table/niceng219er12.appj.tab2/?report=objectonly" target="object" rid-ob="figobniceng219er12appjtab2">Table 10</a></h4><p class="float-caption no_bottom_margin">Studies excluded from the health economic review. </p></div></div></div></div><div id="niceng219er12.appk"><h3>Appendix K. Research recommendations – full details</h3><div id="niceng219er12.appk.s1"><h4>K.1. Research recommendation</h4><p>In people with gout (including people with gout and chronic kidney disease), what is the most clinically and cost effective frequency of serum urate level monitoring when target serum urate level is reached?</p></div><div id="niceng219er12.appk.s2"><h4>K.2. Why this is important</h4><p>Gout is a lifelong condition typically requiring long term medication. Currently there is high variability in serum urate monitoring in GP practices in people who have achieved target serum urate level, ranging from annual to no monitoring at all. Serum urate levels can change over time due to various factors such as adherence, increasing age, weight, medication changes, and changes in patients’ comorbidities and preferences. It is currently unknown what the optimum frequency of serum urate level monitoring is in people who have achieved a target serum urate level. Knowing this would allow us to ensure gout treatment remains clinically and cost-effective by enabling adjustments to treatment to be made, if required, to optimise management and prevent gout flares and hospital admissions. It would also provide the opportunity for patients to discuss their ongoing expectations, concerns and needs regarding treatment, to enhance concordance with taking long term medication.</p></div><div id="niceng219er12.appk.s3"><h4>K.3. Rationale for research recommendation</h4><p id="niceng219er12.appk.et1"><a href="/books/NBK586317/bin/niceng219er12-appk-et1.pdf" class="bk_dwnld_icn bk_dwnld_pdf">Download PDF</a><span class="small"> (108K)</span></p></div><div id="niceng219er12.appk.s4"><h4>K.4. Modified PICO table</h4><p id="niceng219er12.appk.et2"><a href="/books/NBK586317/bin/niceng219er12-appk-et2.pdf" class="bk_dwnld_icn bk_dwnld_pdf">Download PDF</a><span class="small"> (100K)</span></p></div></div></div></div><div class="fm-sec"><div><p>Final version</p></div><div><p>Evidence reviews underpinning recommendation 1.5.15 and research recommendations in the NICE guideline</p><p>National Institute for Health and Care Excellence</p></div><div><p><b>Disclaimer</b>: The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or service users. The recommendations in this guideline are not mandatory and the guideline does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.</p><p>Local commissioners and/or providers have a responsibility to enable the guideline to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with compliance with those duties.</p><p>NICE guidelines cover health and care in England. Decisions on how they apply in other UK countries are made by ministers in the <a href="http://wales.gov.uk/" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">Welsh Government</a>, <a href="http://www.scotland.gov.uk/" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">Scottish Government</a>, and <a href="http://www.northernireland.gov.uk/" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">Northern Ireland Executive</a>. All NICE guidance is subject to regular review and may be updated or withdrawn.</p></div><div class="half_rhythm"><a href="/books/about/copyright/">Copyright</a> © NICE 2022.</div><div class="small"><span class="label">Bookshelf ID: NBK586317</span><span class="label">PMID: <a href="https://pubmed.ncbi.nlm.nih.gov/36395300" title="PubMed record of this title" ref="pagearea=meta&targetsite=entrez&targetcat=link&targettype=pubmed">36395300</a></span></div></div><div class="small-screen-prev"></div><div class="small-screen-next"></div></article><article data-type="table-wrap" id="figobniceng219er12tab1"><div id="niceng219er12.tab1" class="table"><h3><span class="label">Table 1</span><span class="title">PICO characteristics of review question</span></h3><p class="large-table-link" style="display:none"><span class="right"><a href="/books/NBK586317/table/niceng219er12.tab1/?report=objectonly" target="object">View in own window</a></span></p><div class="large_tbl" id="__niceng219er12.tab1_lrgtbl__"><table><tbody><tr><th id="hd_b_niceng219er12.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Population</th><td headers="hd_b_niceng219er12.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<p>Inclusion: Adults (18 years and older) with gout who are having their serum urate level monitored. These patients have already reached target serum urate level and are continuing treatment.</p>
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<p>Strata:<ul><li class="half_rhythm"><div>People with CKD (stage 3)</div></li><li class="half_rhythm"><div>People with CKD (stages 4–5)</div></li><li class="half_rhythm"><div>People without CKD or people with CKD stages 1–2</div></li><li class="half_rhythm"><div>Mixed population (people with CKD and people without CKD)</div></li></ul></p>
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<p>Exclusion: People with calcium pyrophosphate crystal deposition, including pseudogout</p>
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</td></tr><tr><th id="hd_b_niceng219er12.tab1_1_1_2_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Interventions</th><td headers="hd_b_niceng219er12.tab1_1_1_2_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Different monitoring frequencies, examples:<ul><li class="half_rhythm"><div>Every six months</div></li><li class="half_rhythm"><div>Every year</div></li><li class="half_rhythm"><div>Every two years</div></li></ul></td></tr><tr><th id="hd_b_niceng219er12.tab1_1_1_3_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Comparisons</th><td headers="hd_b_niceng219er12.tab1_1_1_3_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<ul><li class="half_rhythm"><div>Compared to each other</div></li><li class="half_rhythm"><div>Control (no monitoring)</div></li></ul>
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</td></tr><tr><th id="hd_b_niceng219er12.tab1_1_1_4_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Outcomes</th><td headers="hd_b_niceng219er12.tab1_1_1_4_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<p>All outcomes are considered equally important for decision making and therefore have all been rated as critical:<ul><li class="half_rhythm"><div>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</div></li><li class="half_rhythm"><div>patient global assessment of treatment success (response to treatment) (e.g. Likert scales, visual analogue scales (VAS), numerical ratings scales (NRS))</div></li><li class="half_rhythm"><div>pain (measured on a visual analogue scale (VAS) or numerical rating scale such as the five-point Likert scale, or reported as pain relief of 50% or greater)</div></li><li class="half_rhythm"><div>joint swelling/joint inflammation</div></li><li class="half_rhythm"><div>joint tenderness</div></li><li class="half_rhythm"><div>serum urate level</div></li><li class="half_rhythm"><div>frequency of flares</div></li><li class="half_rhythm"><div>tophi</div></li><li class="half_rhythm"><div>admissions (hospital and A&E/urgent care)</div></li><li class="half_rhythm"><div>GP visits</div></li></ul></p>
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<p>Timepoints:</p>
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<p>Short-term 6 months, medium 6–12 months, long-term 12+ months</p>
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</td></tr><tr><th id="hd_b_niceng219er12.tab1_1_1_5_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Study design</th><td headers="hd_b_niceng219er12.tab1_1_1_5_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<p>RCT</p>
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<p>Systematic reviews of RCTs</p>
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<p>If insufficient RCT evidence is available (no or little evidence for interventions/comparisons), search for non-randomised studies (prospective and retrospective cohort studies will be considered if they adjust for key confounders:<ul><li class="half_rhythm"><div>Age</div></li><li class="half_rhythm"><div>Gender</div></li></ul></p>
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<p>Published NMAs will be considered for inclusion.</p>
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</td></tr></tbody></table></div></div></article><article data-type="table-wrap" id="figobniceng219er12tab2"><div id="niceng219er12.tab2" class="table"><h3><span class="label">Table 2</span><span class="title">Cost of monitoring for people with comorbidities</span></h3><p class="large-table-link" style="display:none"><span class="right"><a href="/books/NBK586317/table/niceng219er12.tab2/?report=objectonly" target="object">View in own window</a></span></p><div class="large_tbl" id="__niceng219er12.tab2_lrgtbl__"><table class="no_bottom_margin"><thead><tr><th id="hd_h_niceng219er12.tab2_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Resource</th><th id="hd_h_niceng219er12.tab2_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Cost per hour</th><th id="hd_h_niceng219er12.tab2_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Cost per min</th><th id="hd_h_niceng219er12.tab2_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Time (mins)</th><th id="hd_h_niceng219er12.tab2_1_1_1_5" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Total cost</th></tr></thead><tbody><tr><td headers="hd_h_niceng219er12.tab2_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Nurse (Band 5)<sup>(a)</sup></td><td headers="hd_h_niceng219er12.tab2_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£42</td><td headers="hd_h_niceng219er12.tab2_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£0.70</td><td headers="hd_h_niceng219er12.tab2_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">9.25<sup>(b)</sup></td><td headers="hd_h_niceng219er12.tab2_1_1_1_5" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£6.48</td></tr><tr><td headers="hd_h_niceng219er12.tab2_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">GP<sup>(a)</sup></td><td headers="hd_h_niceng219er12.tab2_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£238</td><td headers="hd_h_niceng219er12.tab2_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£3.96</td><td headers="hd_h_niceng219er12.tab2_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">5<sup>(b)</sup></td><td headers="hd_h_niceng219er12.tab2_1_1_1_5" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£19.82</td></tr><tr><td headers="hd_h_niceng219er12.tab2_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Blood test<sup>(c)</sup></td><td headers="hd_h_niceng219er12.tab2_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"></td><td headers="hd_h_niceng219er12.tab2_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"></td><td headers="hd_h_niceng219er12.tab2_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"></td><td headers="hd_h_niceng219er12.tab2_1_1_1_5" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£3.10</td></tr><tr><td headers="hd_h_niceng219er12.tab2_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<b>Total cost</b>
|
|
</td><td headers="hd_h_niceng219er12.tab2_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"></td><td headers="hd_h_niceng219er12.tab2_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"></td><td headers="hd_h_niceng219er12.tab2_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"></td><td headers="hd_h_niceng219er12.tab2_1_1_1_5" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<b>£29.40</b>
|
|
</td></tr></tbody></table></div><div class="tblwrap-foot"><div><dl class="temp-labeled-list small"><dl class="bkr_refwrap"><dt></dt><dd><div><p class="no_margin">Sources:</p></div></dd></dl><dl class="bkr_refwrap"><dt>(a)</dt><dd><div id="niceng219er12.tab2_1"><p class="no_margin">PSSRU 2020<a class="bibr" href="#niceng219er12.ref3" rid="niceng219er12.ref3"><sup>3</sup></a>, including qualification costs (excluding individual and productivity costs)</p></div></dd></dl><dl class="bkr_refwrap"><dt>(b)</dt><dd><div id="niceng219er12.tab2_2"><p class="no_margin">Based on committee opinion</p></div></dd></dl><dl class="bkr_refwrap"><dt>(c)</dt><dd><div id="niceng219er12.tab2_3"><p class="no_margin">NHS reference costs 2019/20<a class="bibr" href="#niceng219er12.ref11" rid="niceng219er12.ref11"><sup>11</sup></a></p></div></dd></dl></dl></div></div></div></article><article data-type="table-wrap" id="figobniceng219er12tab3"><div id="niceng219er12.tab3" class="table"><h3><span class="label">Table 3</span><span class="title">Cost of monitoring for people without comorbidities</span></h3><p class="large-table-link" style="display:none"><span class="right"><a href="/books/NBK586317/table/niceng219er12.tab3/?report=objectonly" target="object">View in own window</a></span></p><div class="large_tbl" id="__niceng219er12.tab3_lrgtbl__"><table class="no_bottom_margin"><thead><tr><th id="hd_h_niceng219er12.tab3_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Resource</th><th id="hd_h_niceng219er12.tab3_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Cost per hour</th><th id="hd_h_niceng219er12.tab3_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Cost per min</th><th id="hd_h_niceng219er12.tab3_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Time (mins)</th><th id="hd_h_niceng219er12.tab3_1_1_1_5" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Total cost</th></tr></thead><tbody><tr><td headers="hd_h_niceng219er12.tab3_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Nurse (Band 5)<sup>(a)</sup></td><td headers="hd_h_niceng219er12.tab3_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£42</td><td headers="hd_h_niceng219er12.tab3_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£0.70</td><td headers="hd_h_niceng219er12.tab3_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">18.5<sup>(b)</sup></td><td headers="hd_h_niceng219er12.tab3_1_1_1_5" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£12.95</td></tr><tr><td headers="hd_h_niceng219er12.tab3_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">GP<sup>(a)</sup></td><td headers="hd_h_niceng219er12.tab3_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£238</td><td headers="hd_h_niceng219er12.tab3_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£3.96</td><td headers="hd_h_niceng219er12.tab3_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">12.5<sup>(b)</sup></td><td headers="hd_h_niceng219er12.tab3_1_1_1_5" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£49.55</td></tr><tr><td headers="hd_h_niceng219er12.tab3_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Blood test<sup>(c)</sup></td><td headers="hd_h_niceng219er12.tab3_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"></td><td headers="hd_h_niceng219er12.tab3_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"></td><td headers="hd_h_niceng219er12.tab3_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"></td><td headers="hd_h_niceng219er12.tab3_1_1_1_5" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£3.10</td></tr><tr><td headers="hd_h_niceng219er12.tab3_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<b>Total cost</b>
|
|
</td><td headers="hd_h_niceng219er12.tab3_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"></td><td headers="hd_h_niceng219er12.tab3_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"></td><td headers="hd_h_niceng219er12.tab3_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"></td><td headers="hd_h_niceng219er12.tab3_1_1_1_5" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<b>£65.61</b>
|
|
</td></tr></tbody></table></div><div class="tblwrap-foot"><div><dl class="temp-labeled-list small"><dl class="bkr_refwrap"><dt></dt><dd><div><p class="no_margin">Sources:</p></div></dd></dl><dl class="bkr_refwrap"><dt>(a)</dt><dd><div id="niceng219er12.tab3_1"><p class="no_margin">PSSRU 2020<a class="bibr" href="#niceng219er12.ref3" rid="niceng219er12.ref3"><sup>3</sup></a>, including qualification costs (excluding individual and productivity costs)</p></div></dd></dl><dl class="bkr_refwrap"><dt>(b)</dt><dd><div id="niceng219er12.tab3_2"><p class="no_margin">Based on committee opinion</p></div></dd></dl><dl class="bkr_refwrap"><dt>(c)</dt><dd><div id="niceng219er12.tab3_3"><p class="no_margin">NHS reference costs 2019/20<a class="bibr" href="#niceng219er12.ref11" rid="niceng219er12.ref11"><sup>11</sup></a></p></div></dd></dl></dl></div></div></div></article><article data-type="table-wrap" id="figobniceng219er12tab4"><div id="niceng219er12.tab4" class="table"><h3><span class="label">Table 4</span><span class="title">Cost of a gout flare</span></h3><p class="large-table-link" style="display:none"><span class="right"><a href="/books/NBK586317/table/niceng219er12.tab4/?report=objectonly" target="object">View in own window</a></span></p><div class="large_tbl" id="__niceng219er12.tab4_lrgtbl__"><table><thead><tr><th id="hd_h_niceng219er12.tab4_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Scenario</th><th id="hd_h_niceng219er12.tab4_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Hospital</th><th id="hd_h_niceng219er12.tab4_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">GP visit</th><th id="hd_h_niceng219er12.tab4_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Repeat prescription</th><th id="hd_h_niceng219er12.tab4_1_1_1_5" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Self-managed</th><th id="hd_h_niceng219er12.tab4_1_1_1_6" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Total cost of a gout flare</th></tr></thead><tbody><tr><td headers="hd_h_niceng219er12.tab4_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Scenario 1</td><td headers="hd_h_niceng219er12.tab4_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">1%</td><td headers="hd_h_niceng219er12.tab4_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">25%</td><td headers="hd_h_niceng219er12.tab4_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">54%</td><td headers="hd_h_niceng219er12.tab4_1_1_1_5" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">20%</td><td headers="hd_h_niceng219er12.tab4_1_1_1_6" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£30.52</td></tr><tr><td headers="hd_h_niceng219er12.tab4_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Scenario 2</td><td headers="hd_h_niceng219er12.tab4_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">5%</td><td headers="hd_h_niceng219er12.tab4_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">25%</td><td headers="hd_h_niceng219er12.tab4_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">50%</td><td headers="hd_h_niceng219er12.tab4_1_1_1_5" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">20%</td><td headers="hd_h_niceng219er12.tab4_1_1_1_6" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£55.64</td></tr><tr><td headers="hd_h_niceng219er12.tab4_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Scenario 3</td><td headers="hd_h_niceng219er12.tab4_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">1%</td><td headers="hd_h_niceng219er12.tab4_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">25%</td><td headers="hd_h_niceng219er12.tab4_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">44%</td><td headers="hd_h_niceng219er12.tab4_1_1_1_5" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">30%</td><td headers="hd_h_niceng219er12.tab4_1_1_1_6" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£28.49</td></tr><tr><td headers="hd_h_niceng219er12.tab4_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Scenario 4</td><td headers="hd_h_niceng219er12.tab4_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">5%</td><td headers="hd_h_niceng219er12.tab4_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">25%</td><td headers="hd_h_niceng219er12.tab4_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">40%</td><td headers="hd_h_niceng219er12.tab4_1_1_1_5" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">30%</td><td headers="hd_h_niceng219er12.tab4_1_1_1_6" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£53.61</td></tr><tr><td headers="hd_h_niceng219er12.tab4_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Scenario 5</td><td headers="hd_h_niceng219er12.tab4_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">1%</td><td headers="hd_h_niceng219er12.tab4_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">15%</td><td headers="hd_h_niceng219er12.tab4_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">64%</td><td headers="hd_h_niceng219er12.tab4_1_1_1_5" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">20%</td><td headers="hd_h_niceng219er12.tab4_1_1_1_6" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£29.61</td></tr><tr><td headers="hd_h_niceng219er12.tab4_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Scenario 6</td><td headers="hd_h_niceng219er12.tab4_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">5%</td><td headers="hd_h_niceng219er12.tab4_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">15%</td><td headers="hd_h_niceng219er12.tab4_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">60%</td><td headers="hd_h_niceng219er12.tab4_1_1_1_5" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">20%</td><td headers="hd_h_niceng219er12.tab4_1_1_1_6" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£54.59</td></tr><tr><td headers="hd_h_niceng219er12.tab4_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Scenario 7</td><td headers="hd_h_niceng219er12.tab4_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">1%</td><td headers="hd_h_niceng219er12.tab4_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">15%</td><td headers="hd_h_niceng219er12.tab4_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">54%</td><td headers="hd_h_niceng219er12.tab4_1_1_1_5" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">30%</td><td headers="hd_h_niceng219er12.tab4_1_1_1_6" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£27.22</td></tr><tr><td headers="hd_h_niceng219er12.tab4_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Scenario 8</td><td headers="hd_h_niceng219er12.tab4_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">5%</td><td headers="hd_h_niceng219er12.tab4_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">15%</td><td headers="hd_h_niceng219er12.tab4_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">50%</td><td headers="hd_h_niceng219er12.tab4_1_1_1_5" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">30%</td><td headers="hd_h_niceng219er12.tab4_1_1_1_6" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£52.20</td></tr></tbody></table></div></div></article><article data-type="table-wrap" id="figobniceng219er12tab5"><div id="niceng219er12.tab5" class="table"><h3><span class="label">Table 5</span><span class="title">Results for the number of gout flares required to be avoided per person for the cost of monitoring to break even</span></h3><p class="large-table-link" style="display:none"><span class="right"><a href="/books/NBK586317/table/niceng219er12.tab5/?report=objectonly" target="object">View in own window</a></span></p><div class="large_tbl" id="__niceng219er12.tab5_lrgtbl__"><table><thead><tr><th id="hd_h_niceng219er12.tab5_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Scenario</th><th id="hd_h_niceng219er12.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Number of gout flares avoided per person for the cost of monitoring to break even</th></tr></thead><tbody><tr><td headers="hd_h_niceng219er12.tab5_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Scenario 1</td><td headers="hd_h_niceng219er12.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">1.12</td></tr><tr><td headers="hd_h_niceng219er12.tab5_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Scenario 2</td><td headers="hd_h_niceng219er12.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">0.61</td></tr><tr><td headers="hd_h_niceng219er12.tab5_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Scenario 3</td><td headers="hd_h_niceng219er12.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">1.20</td></tr><tr><td headers="hd_h_niceng219er12.tab5_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Scenario 4</td><td headers="hd_h_niceng219er12.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">0.64</td></tr><tr><td headers="hd_h_niceng219er12.tab5_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Scenario 5</td><td headers="hd_h_niceng219er12.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">1.15</td></tr><tr><td headers="hd_h_niceng219er12.tab5_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Scenario 6</td><td headers="hd_h_niceng219er12.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">0.63</td></tr><tr><td headers="hd_h_niceng219er12.tab5_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Scenario 7</td><td headers="hd_h_niceng219er12.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">1.26</td></tr><tr><td headers="hd_h_niceng219er12.tab5_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Scenario 8</td><td headers="hd_h_niceng219er12.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">0.65</td></tr></tbody></table></div></div></article><article data-type="table-wrap" id="figobniceng219er12tab6"><div id="niceng219er12.tab6" class="table"><h3><span class="label">Table 6</span><span class="title">Unit costs</span></h3><p class="large-table-link" style="display:none"><span class="right"><a href="/books/NBK586317/table/niceng219er12.tab6/?report=objectonly" target="object">View in own window</a></span></p><div class="large_tbl" id="__niceng219er12.tab6_lrgtbl__"><table class="no_bottom_margin"><thead><tr><th id="hd_h_niceng219er12.tab6_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Resource</th><th id="hd_h_niceng219er12.tab6_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Unit costs</th></tr></thead><tbody><tr><td headers="hd_h_niceng219er12.tab6_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Primary care Practice Nurse (Band 5), cost per hour<sup>(a)</sup></td><td headers="hd_h_niceng219er12.tab6_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£42</td></tr><tr><td headers="hd_h_niceng219er12.tab6_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">General Practitioner, cost per consultation (9.22 mins)<sup>(a)</sup></td><td headers="hd_h_niceng219er12.tab6_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£37</td></tr><tr><td headers="hd_h_niceng219er12.tab6_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Cost of blood test (excluding time to take blood)<sup>(b)</sup></td><td headers="hd_h_niceng219er12.tab6_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£3–£4</td></tr></tbody></table></div><div class="tblwrap-foot"><div><dl class="temp-labeled-list small"><dl class="bkr_refwrap"><dt></dt><dd><div><p class="no_margin">1. Source: PSSRU 2020<a class="bibr" href="#niceng219er12.ref3" rid="niceng219er12.ref3"><sup>3</sup></a>, including qualification costs (excluding individual and productivity costs)</p></div></dd></dl><dl class="bkr_refwrap"><dt></dt><dd><div><p class="no_margin">2. Source: NHS reference costs 2019/2020<a class="bibr" href="#niceng219er12.ref11" rid="niceng219er12.ref11"><sup>11</sup></a>: directly accessed pathology services, haematology and phlebotomy respectively.</p></div></dd></dl></dl></div></div></div></article><article data-type="table-wrap" id="figobniceng219er12appjtab1"><div id="niceng219er12.appj.tab1" class="table"><h3><span class="label">Table 9</span><span class="title">Studies excluded from the clinical review</span></h3><p class="large-table-link" style="display:none"><span class="right"><a href="/books/NBK586317/table/niceng219er12.appj.tab1/?report=objectonly" target="object">View in own window</a></span></p><div class="large_tbl" id="__niceng219er12.appj.tab1_lrgtbl__"><table><thead><tr><th id="hd_h_niceng219er12.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Study</th><th id="hd_h_niceng219er12.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Exclusion reason</th></tr></thead><tbody><tr><td headers="hd_h_niceng219er12.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Alvarado-de la Barrera 2020<a class="bibr" href="#niceng219er12.ref1" rid="niceng219er12.ref1"><sup>1</sup></a></td><td headers="hd_h_niceng219er12.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Incorrect analysis/comparison - study aimed to determine proportion of patients achieving target urate level for patients with non-severe and severe gout, as well as remission after 5 years of follow-up, before and after study, no adjusted multivariate analysis</td></tr><tr><td headers="hd_h_niceng219er12.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Bai 2020<a class="bibr" href="#niceng219er12.ref2" rid="niceng219er12.ref2"><sup>2</sup></a></td><td headers="hd_h_niceng219er12.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Incorrect study design- cross-sectional study, study analysed risk factors for frequency of flares</td></tr><tr><td headers="hd_h_niceng219er12.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Edwards 2011<a class="bibr" href="#niceng219er12.ref5" rid="niceng219er12.ref5"><sup>5</sup></a></td><td headers="hd_h_niceng219er12.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Incorrect analysis - study analysed correlations between flares, SF-36 and daily reported activity loss measures</td></tr><tr><td headers="hd_h_niceng219er12.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Harrold 2010<a class="bibr" href="#niceng219er12.ref7" rid="niceng219er12.ref7"><sup>7</sup></a></td><td headers="hd_h_niceng219er12.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Incorrect analysis/comparison - study aimed to determine factors associated with resuming therapy</td></tr><tr><td headers="hd_h_niceng219er12.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">McLachlan 2011<a class="bibr" href="#niceng219er12.ref9" rid="niceng219er12.ref9"><sup>9</sup></a></td><td headers="hd_h_niceng219er12.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Incorrect analysis/incorrect comparison - cohort study assessed cardiovascular disease risk management intervention</td></tr><tr><td headers="hd_h_niceng219er12.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Perez-Ruiz 2011<a class="bibr" href="#niceng219er12.ref12" rid="niceng219er12.ref12"><sup>12</sup></a></td><td headers="hd_h_niceng219er12.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Incorrect analysis/incorrect comparison - study analysed risk factors for crystal proven recurrence of gout</td></tr><tr><td headers="hd_h_niceng219er12.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Raebel 2006<a class="bibr" href="#niceng219er12.ref13" rid="niceng219er12.ref13"><sup>13</sup></a></td><td headers="hd_h_niceng219er12.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Incorrect analysis/comparison - adjusted analysis of factors associated with lack of serum creatinine monitoring during Allopurinol therapy</td></tr><tr><td headers="hd_h_niceng219er12.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Shoji 2004<a class="bibr" href="#niceng219er12.ref15" rid="niceng219er12.ref15"><sup>15</sup></a></td><td headers="hd_h_niceng219er12.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Incorrect analysis/incorrect comparison - retrospective study analysed risk factors (serum urate levels) for recurrence of acute gouty attacks</td></tr><tr><td headers="hd_h_niceng219er12.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Wall 2010<a class="bibr" href="#niceng219er12.ref16" rid="niceng219er12.ref16"><sup>16</sup></a></td><td headers="hd_h_niceng219er12.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Incorrect analysis/incorrect comparison - study compared two different general internal medicine practices in terms of compliance to guidelines for treatment of gout</td></tr><tr><td headers="hd_h_niceng219er12.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Yeo 2019<a class="bibr" href="#niceng219er12.ref17" rid="niceng219er12.ref17"><sup>17</sup></a></td><td headers="hd_h_niceng219er12.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Incorrect study design- cross-sectional study, study assessed point prevalence of gout, gout treatment and achievement of target SU among adults treated with long-term dialysis.</td></tr></tbody></table></div></div></article><article data-type="table-wrap" id="figobniceng219er12appjtab2"><div id="niceng219er12.appj.tab2" class="table"><h3><span class="label">Table 10</span><span class="title">Studies excluded from the health economic review</span></h3><p class="large-table-link" style="display:none"><span class="right"><a href="/books/NBK586317/table/niceng219er12.appj.tab2/?report=objectonly" target="object">View in own window</a></span></p><div class="large_tbl" id="__niceng219er12.appj.tab2_lrgtbl__"><table><thead><tr><th id="hd_h_niceng219er12.appj.tab2_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Reference</th><th id="hd_h_niceng219er12.appj.tab2_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Reason for exclusion</th></tr></thead><tbody><tr><td headers="hd_h_niceng219er12.appj.tab2_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Hill-McManus 2018 <a class="bibr" href="#niceng219er12.ref8" rid="niceng219er12.ref8"><sup>8</sup></a></td><td headers="hd_h_niceng219er12.appj.tab2_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Excluded as rated not applicable. The study did not compare different monitoring strategies but compared the cost effectiveness of different ULT strategies and modelled their effectiveness based on medication adherence.</td></tr><tr><td headers="hd_h_niceng219er12.appj.tab2_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Robinson 2018 <a class="bibr" href="#niceng219er12.ref14" rid="niceng219er12.ref14"><sup>14</sup></a></td><td headers="hd_h_niceng219er12.appj.tab2_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Excluded as rated very serious limitations. The studies main data inputs and assumptions concerning the efficacy of strategies were based on non-RCT evidence and estimates. Unreliable ICERs were reported whereby the incremental values reported did not equate to the overall ICER. In addition, the majority of values used in the sensitivity analysis were estimates. Also rated partially applicable, reasons include: Australian setting may not reflect current NHS context and SF-36 values were used to obtain QALYs.</td></tr></tbody></table></div></div></article></div><div id="jr-scripts"><script src="/corehtml/pmc/jatsreader/ptpmc_3.22/js/libs.min.js"> </script><script src="/corehtml/pmc/jatsreader/ptpmc_3.22/js/jr.min.js"> </script></div></div>
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