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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-niceng219er13-lrg.png" alt="Cover of Evidence review for follow-up for people with gout after a gout flare" /></a></div><div class="bkr_bib"><h1 id="_NBK586318_"><span itemprop="name">Evidence review for follow-up for people with gout after a gout flare</span></h1><div class="subtitle">Gout: diagnosis and management</div><p><b>Evidence review M</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="niceng219er13.s1"><h2 id="_niceng219er13_s1_">1. Follow-up for people with gout after a gout flare</h2><div id="niceng219er13.s1.1"><h3>1.1. Review question: What follow-up should be offered to people with gout after a gout flare?</h3><div id="niceng219er13.s1.1.1"><h4>1.1.1. Introduction</h4><p>Gout flares are characterised by rapid onset of severe pain, joint swelling and erythema. A flare can be an indication that current treatment is ineffective, and each flare exposes the patient to painful, debilitating symptoms. Importantly, gout continues to affect patients insidiously between flares.</p><p>Reviewing a person following a flare provides an opportunity to re-evaluate their treatment, lifestyle, and their understanding of the condition. Currently there is no standardisation in practice regarding when or if a follow-up review should occur or what it should comprise of. This evidence review aims to determine what follow-up should be offered to people after a gout flare.</p></div><div id="niceng219er13.s1.1.2"><h4>1.1.2. Summary of the protocol</h4><p>For full details see the review protocol in <a href="#niceng219er13.appa">Appendix A</a>.</p><div class="iconblock whole_rhythm clearfix ten_col table-wrap" id="figniceng219er13tab1"><a href="/books/NBK586318/table/niceng219er13.tab1/?report=objectonly" target="object" title="Table 1" class="img_link icnblk_img figpopup" rid-figpopup="figniceng219er13tab1" rid-ob="figobniceng219er13tab1"><img class="small-thumb" src="/books/NBK586318/table/niceng219er13.tab1/?report=thumb" src-large="/books/NBK586318/table/niceng219er13.tab1/?report=previmg" alt="Table 1. PICO characteristics of review question." /></a><div class="icnblk_cntnt"><h4 id="niceng219er13.tab1"><a href="/books/NBK586318/table/niceng219er13.tab1/?report=objectonly" target="object" rid-ob="figobniceng219er13tab1">Table 1</a></h4><p class="float-caption no_bottom_margin">PICO characteristics of review question. </p></div></div></div><div id="niceng219er13.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>.</p><p>Methods specific to this review question are described in the review protocol in <a href="#niceng219er13.appa">Appendix A</a> and the methods document. 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="niceng219er13.s1.1.4"><h4>1.1.4. Effectiveness evidence</h4><div id="niceng219er13.s1.1.4.1"><h5>1.1.4.1. Included studies</h5><p>No relevant clinical studies comparing follow-up care strategies were identified.</p><p>See also the study selection flow chart in <a href="#niceng219er13.appc">Appendix C</a>.</p></div><div id="niceng219er13.s1.1.4.2"><h5>1.1.4.2. Excluded studies</h5><p>See the excluded studies list in <a href="#niceng219er13.appj">Appendix J</a>.</p></div></div><div id="niceng219er13.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="niceng219er13.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="niceng219er13.s1.1.7"><h4>1.1.7. Economic evidence</h4><div id="niceng219er13.s1.1.7.1"><h5>1.1.7.1. Included studies</h5><p>No health economic studies were included.</p></div><div id="niceng219er13.s1.1.7.2"><h5>1.1.7.2. Excluded studies</h5><p>No relevant health economic studies were excluded due to assessment of limited applicability or methodological limitations.</p><p>See also the health economic study selection flow chart in <a href="#niceng219er13.appg">Appendix G</a></p></div></div><div id="niceng219er13.s1.1.8"><h4>1.1.8. Economic model</h4><p>This area was not prioritised for new cost-effectiveness analysis.</p></div><div id="niceng219er13.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="figniceng219er13tab2"><a href="/books/NBK586318/table/niceng219er13.tab2/?report=objectonly" target="object" title="Table 2" class="img_link icnblk_img figpopup" rid-figpopup="figniceng219er13tab2" rid-ob="figobniceng219er13tab2"><img class="small-thumb" src="/books/NBK586318/table/niceng219er13.tab2/?report=thumb" src-large="/books/NBK586318/table/niceng219er13.tab2/?report=previmg" alt="Table 2. Unit costs." /></a><div class="icnblk_cntnt"><h4 id="niceng219er13.tab2"><a href="/books/NBK586318/table/niceng219er13.tab2/?report=objectonly" target="object" rid-ob="figobniceng219er13tab2">Table 2</a></h4><p class="float-caption no_bottom_margin">Unit costs. </p></div></div></div><div id="niceng219er13.s1.1.10"><h4>1.1.10. Evidence statements</h4><div id="niceng219er13.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="niceng219er13.s1.1.11"><h4>1.1.11. The committee’s discussion and interpretation of the evidence</h4><div id="niceng219er13.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 (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.</p><p>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.</p><p>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).</p></div><div id="niceng219er13.s1.1.11.2"><h5>1.1.11.2. The quality of the evidence</h5><p>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.</p><p>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.</p></div><div id="niceng219er13.s1.1.11.3"><h5>1.1.11.3. Benefits and harms</h5><p>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.</p><p>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)<a class="bibr" href="#niceng219er13.ref6" rid="niceng219er13.ref6"><sup>6</sup></a> 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.</p><p>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.</p><p>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.</p><p>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.</p></div><div id="niceng219er13.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 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.</p><p>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.</p><p>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.</p><p>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 2018<a class="bibr" href="#niceng219er13.ref3" rid="niceng219er13.ref3"><sup>3</sup></a> 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.</p><p>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.</p></div><div id="niceng219er13.s1.1.11.5"><h5>1.1.11.5. Other factors the committee took into account</h5><p>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.</p></div></div><div id="niceng219er13.s1.1.12"><h4>1.1.12. Recommendations supported by this evidence review</h4><p>This evidence review supports recommendations 1.3.6 and the research recommendation on the effectiveness and patient acceptability of different approaches of follow-up, including provision of patient information and for managing gout flares?</p></div></div></div><div id="niceng219er13.rl.r1"><h2 id="_niceng219er13_rl_r1_">1.1.13. References</h2><dl class="temp-labeled-list"><dl class="bkr_refwrap"><dt>1.</dt><dd><div class="bk_ref" id="niceng219er13.ref1">Barber
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C, Thompson
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K, Hanly
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JG. Impact of a rheumatology consultation service on the diagnostic accuracy and management of gout in hospitalized patients. Journal of Rheumatology. 2009; 36(8):1699–1704 [<a href="https://pubmed.ncbi.nlm.nih.gov/19567626" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 19567626</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>2.</dt><dd><div class="bk_ref" id="niceng219er13.ref2">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>3.</dt><dd><div class="bk_ref" id="niceng219er13.ref3">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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D
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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>4.</dt><dd><div class="bk_ref" id="niceng219er13.ref4">Fautrel
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B, Belhassen
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M, Hudry
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C, Woronoff-Lemsi
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MC, Levy-Bachelot
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L, Van Ganse
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E
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et al
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Predictive factors of tumour necrosis inhibitor treatment persistence for rheumatoid arthritis: An observational study in 8052 patients. Joint, Bone, Spine: Revue du Rhumatisme. 2020; 87(2):137–139 [<a href="https://pubmed.ncbi.nlm.nih.gov/31669808" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 31669808</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>5.</dt><dd><div class="bk_ref" id="niceng219er13.ref5">Goossens
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J, Lancrenon
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S, Lanz
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S, Ea
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HK, Lambert
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C, Guggenbuhl
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P
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et al
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GOSPEL 3: Management of gout by primary-care physicians and office-based rheumatologists in France in the early 21st century - comparison with 2006 EULAR Recommendations. Joint, Bone, Spine: Revue du Rhumatisme. 2017; 84(4):447–453 [<a href="https://pubmed.ncbi.nlm.nih.gov/28411137" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 28411137</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>6.</dt><dd><div class="bk_ref" id="niceng219er13.ref6">Multimorbidity
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Guthrie B. 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="niceng219er13.ref7">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> [<a href="https://pubmed.ncbi.nlm.nih.gov/26677490" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 26677490</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>8.</dt><dd><div class="bk_ref" id="niceng219er13.ref8">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></div><div id="appendixesappgroup1"><h2 id="_appendixesappgroup1_">Appendices</h2><div id="niceng219er13.appa"><h3>Appendix A. Review protocols</h3><p id="niceng219er13.appa.et1"><a href="/books/NBK586318/bin/niceng219er13-appa-et1.pdf" class="bk_dwnld_icn bk_dwnld_pdf">Download PDF</a><span class="small"> (243K)</span></p></div><div id="niceng219er13.appb"><h3>Appendix B. Literature search strategies</h3><ul><li class="half_rhythm"><div>What follow-up should be offered to people with gout after a gout flare?</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="#niceng219er13.ref7" rid="niceng219er13.ref7"><sup>7</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="niceng219er13.appb.et1"><a href="/books/NBK586318/bin/niceng219er13-appb-et1.pdf" class="bk_dwnld_icn bk_dwnld_pdf">B.1. Clinical search literature search strategy</a><span class="small"> (PDF, 200K)</span></p><p id="niceng219er13.appb.et2"><a href="/books/NBK586318/bin/niceng219er13-appb-et2.pdf" class="bk_dwnld_icn bk_dwnld_pdf">B.2. Health Economics literature search strategy</a><span class="small"> (PDF, 162K)</span></p></div><div id="niceng219er13.appc"><h3>Appendix C. Effectiveness evidence study selection</h3><p id="niceng219er13.appc.et1"><a href="/books/NBK586318/bin/niceng219er13-appc-et1.pdf" class="bk_dwnld_icn bk_dwnld_pdf">Download PDF</a><span class="small"> (105K)</span></p></div><div id="niceng219er13.appd"><h3>Appendix D. Effectiveness evidence</h3><p>No studies were included.</p></div><div id="niceng219er13.appe"><h3>Appendix E. Forest plots</h3><p>No studies were included.</p></div><div id="niceng219er13.appf"><h3>Appendix F. GRADE and/or GRADE-CERQual tables</h3><p>No studies were included</p></div><div id="niceng219er13.appg"><h3>Appendix G. Economic evidence study selection</h3><p id="niceng219er13.appg.et1"><a href="/books/NBK586318/bin/niceng219er13-appg-et1.pdf" class="bk_dwnld_icn bk_dwnld_pdf">Download PDF</a><span class="small"> (134K)</span></p></div><div id="niceng219er13.apph"><h3>Appendix H. Economic evidence tables</h3><p>None.</p></div><div id="niceng219er13.appi"><h3>Appendix I. Health economic model</h3><p>No original economic modelling was undertaken for this review question.</p></div><div id="niceng219er13.appj"><h3>Appendix J. Excluded studies</h3><div id="niceng219er13.appj.s1"><h4>Clinical studies</h4><p id="niceng219er13.appj.et1"><a href="/books/NBK586318/bin/niceng219er13-appj-et1.pdf" class="bk_dwnld_icn bk_dwnld_pdf">Download PDF</a><span class="small"> (106K)</span></p></div><div id="niceng219er13.appj.s2"><h4>Health Economic studies</h4><p>None</p></div></div><div id="niceng219er13.appk"><h3>Appendix K. Research recommendations – full details</h3><div id="niceng219er13.appk.s1"><h4>K.1.1. Research recommendation</h4><p>What is the clinical and cost effectiveness and patient acceptability of different approaches to follow-up, including provision of patient information and managing gout flares?</p></div><div id="niceng219er13.appk.s2"><h4>K.1.2. Why this is important</h4><p>Gout is the most common type of inflammatory arthritis, causing both painful inflammatory gout flares and more insidious inflammation between flares. Most patients and healthcare professionals consider flares to be the only effect of gout. Prevalence and severity of gout are both associated with lower levels of education and lower socio-economic status whilst more frequent flares are associated with work absenteeism. Coupled with persisting and incorrect societal beliefs that gout is a self-inflicted lifestyle disease, these misconceptions often prevent gout patients receiving timely follow-up for their gout flares and explanation of the long-term effects of gout and available treatment which would help them manage their condition. There is a need for better provision of patient information and understanding of how this information should be provided, by whom and when to ensure that this provision of information is acceptable to and understood by the patient. This would facilitate the provision of clinically and cost-effective patient information and advice and reduce inequalities and variation in care.</p></div><div id="niceng219er13.appk.s3"><h4>K.1.3. Rationale for research recommendation</h4><p id="niceng219er13.appk.et1"><a href="/books/NBK586318/bin/niceng219er13-appk-et1.pdf" class="bk_dwnld_icn bk_dwnld_pdf">Download PDF</a><span class="small"> (186K)</span></p></div><div id="niceng219er13.appk.s4"><h4>K.1.4. Modified PICO table</h4><p id="niceng219er13.appk.et2"><a href="/books/NBK586318/bin/niceng219er13-appk-et2.pdf" class="bk_dwnld_icn bk_dwnld_pdf">Download PDF</a><span class="small"> (141K)</span></p></div></div></div></div><div class="fm-sec"><div><p>Final version</p></div><div><p>Evidence reviews underpinning recommendation 1.3.6 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: NBK586318</span><span class="label">PMID: <a href="https://pubmed.ncbi.nlm.nih.gov/36395302" title="PubMed record of this title" ref="pagearea=meta&targetsite=entrez&targetcat=link&targettype=pubmed">36395302</a></span></div></div><div class="small-screen-prev"></div><div class="small-screen-next"></div></article><article data-type="table-wrap" id="figobniceng219er13tab1"><div id="niceng219er13.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/NBK586318/table/niceng219er13.tab1/?report=objectonly" target="object">View in own window</a></span></p><div class="large_tbl" id="__niceng219er13.tab1_lrgtbl__"><table><tbody><tr><th id="hd_b_niceng219er13.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Population</th><td headers="hd_b_niceng219er13.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<ul><li class="half_rhythm"><div>Inclusion: Adults (18 years and older) with gout who have had gout flare(s)</div></li><li class="half_rhythm"><div>Strata: None</div></li><li class="half_rhythm"><div>Exclusion: people with calcium pyrophosphate crystal deposition, including pseudogout</div></li></ul>
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</td></tr><tr><th id="hd_b_niceng219er13.tab1_1_1_2_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Interventions</th><td headers="hd_b_niceng219er13.tab1_1_1_2_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<ul><li class="half_rhythm"><div>Follow-up care strategies, including:</div></li><li class="half_rhythm"><div>Specific frequencies and durations</div></li><li class="half_rhythm"><div>Led by specific healthcare professionals</div></li><li class="half_rhythm"><div>Settings (community versus secondary/hospital-based care)</div></li><li class="half_rhythm"><div>Patient- tailored</div></li></ul>
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</td></tr><tr><th id="hd_b_niceng219er13.tab1_1_1_3_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Comparisons</th><td headers="hd_b_niceng219er13.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>Within-type comparisons (e.g. community versus secondary/hospital-based care)</div></li><li class="half_rhythm"><div>Compared to each other</div></li><li class="half_rhythm"><div>Standard/usual care</div></li><li class="half_rhythm"><div>Control (no follow-up)</div></li></ul>
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</td></tr><tr><th id="hd_b_niceng219er13.tab1_1_1_4_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Outcomes</th><td headers="hd_b_niceng219er13.tab1_1_1_4_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<ul><li class="half_rhythm"><div>All outcomes are considered equally important for decision making and therefore have all been rated as critical:<ul class="circle"><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>frequency of flares</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>proportion of people with gout using ULT</div></li><li class="half_rhythm"><div>patient awareness of their condition/treatment</div></li><li class="half_rhythm"><div>serum urate levels</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></div></li><li class="half_rhythm"><div>Timepoints: short-term (less than three months), medium-term (three to 12 months) and long-term (more than 12 months) duration.</div></li></ul>
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</td></tr><tr><th id="hd_b_niceng219er13.tab1_1_1_5_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Study design</th><td headers="hd_b_niceng219er13.tab1_1_1_5_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<ul><li class="half_rhythm"><div>RCT</div></li><li class="half_rhythm"><div>Systematic reviews of RCTs</div></li><li class="half_rhythm"><div>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 class="circle"><li class="half_rhythm"><div>Age</div></li><li class="half_rhythm"><div>Gender</div></li></ul></div></li><li class="half_rhythm"><div>Published NMAs will be considered for inclusion.</div></li></ul>
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</td></tr></tbody></table></div></div></article><article data-type="table-wrap" id="figobniceng219er13tab2"><div id="niceng219er13.tab2" class="table"><h3><span class="label">Table 2</span><span class="title">Unit costs</span></h3><p class="large-table-link" style="display:none"><span class="right"><a href="/books/NBK586318/table/niceng219er13.tab2/?report=objectonly" target="object">View in own window</a></span></p><div class="large_tbl" id="__niceng219er13.tab2_lrgtbl__"><table class="no_bottom_margin"><thead><tr><th id="hd_h_niceng219er13.tab2_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Resource</th><th id="hd_h_niceng219er13.tab2_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_niceng219er13.tab2_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_niceng219er13.tab2_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£42</td></tr><tr><td headers="hd_h_niceng219er13.tab2_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">General Practitioner, cost per consultation (9.22 minutes)<sup>(a)</sup></td><td headers="hd_h_niceng219er13.tab2_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£37</td></tr><tr><td headers="hd_h_niceng219er13.tab2_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_niceng219er13.tab2_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="#niceng219er13.ref2" rid="niceng219er13.ref2"><sup>2</sup></a>; Including qualification costs but 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="#niceng219er13.ref8" rid="niceng219er13.ref8"><sup>8</sup></a>: directly accessed pathology services, haematology and phlebotomy respectively.</p></div></dd></dl></dl></div></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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