Cost-effectiveness of nurse-led home monitoring of serum uric acid values for gout patients in secondary care: a modelling study
Jeffrey Van Der Ven, Msc; Marcel Flendrie, Md, Phd; Fenne Van Dijck; Maike Wientjes, Msc; Noortje Van Herwaarden, Md, Phd; Philip L Riches, Md, Phd; Bart J.f. Van Den Bemt, Prof., Phd; Lise M. Verhoef, Phd
Affiliation(s):
Sint Maartenskliniek
Background: A treat-to-target (T2T) approach to reduce serum urate (SU) levels is recommended in all gout patients receiving urate-lowering therapy (ULT) to control symptoms. While efficacious and recommended, SU control using ULT is often not reached. This problem continues to grow due to a growing patient population and increasing shortages of healthcare personnel, necessitating alternative care approaches. We know that nurse-led care and self-monitoring can both support this T2T approach1,2. Combining self-monitoring with nurse support during the initiation phase of ULT is a promising strategy to reduce physician visits and costs while maintaining or further improving quality of care. When introducing new interventions, cost-effectiveness analysis modelling provides information on the potential costs and benefits in health outcomes.
Objectives: To estimate the cost-effectiveness of nurse-led home monitoring of SU compared to usual care for gout patients starting ULT in secondary care, from a societal perspective, using a decision modeling approach. A secondary objective was to estimate the effect of this intervention on time investments from nurses and rheumatologists.
Methods: The intervention involves rheumatology nurses remotely supporting patients using urate-lowering therapy via a T2T approach with at-home point-of-care testing (POCT) for SU. Usual care uses the same T2T strategy but relies on hospital lab tests and rheumatologist visits. The model spans two years, with a 6-month initiation phase modeled using a decision tree and three 6-month maintenance cycles modeled via a Markov framework.
Patients were categorized into four SU-based health states: one on-target (SU < 0.36 mmol/L) and three off-target (+0.12 mmol/L increments). Adherence to ULT in usual care was based on internal hospital data, while intervention adherence and health state transitions were informed by literature and expert input.2 SU target probabilities, flare rates, utilities, and disutility for gout flares came from literature as well.3 Costs, calculated per Dutch healthcare guidelines4, included ULT medication, rheumatologist and rheumatology nurse time, lab/home blood monitoring, travel costs, work productivity losses, and flare-related hospitalization and outpatient visits.
Outcomes were expressed as Quality-Adjusted Life Years (QALYs). Cost-effectiveness was evaluated using probabilistic sensitivity analyses (PSA) with Monte Carlo simulations (1,000 iterations) and incremental net monetary benefit (iNMB) at a €20,000/QALY threshold. Scenarios, detailed in Table 1, explored uncertainties in adherence rates and nurse time inputs.
Results: Home monitoring was cost-effective with a mean iNMB of €130.20 (CI: -14.17 – 304.51), and resulted in little QALY differences from 1.45 (CI: 1.39 – 1.52) in the usual care group to 1.46 (CI: 1.39 – 1.45) in the intervention group (2 years) (Figure 1). Rheumatologists saved 42.74 minutes (CI: -120.02, 9.49), while nurses spent 51.21 (CI: 3.98 – 140.52) minutes extra (2 years) (Table 1). The probability of being cost-effective was 0.96. Costs, QALYs, cost-effectiveness and time investment/savings for rheumatology nurses and rheumatologists under alternative scenarios are shown in Table 2.
Conclusion: Rheumatology nurse-led home monitoring of SU values for gout in secondary care can be cost-effective by reducing costs and improving health outcomes, although effects are modest. Future studies should focus on ways to reduce time needed from nurses while maintaining adherence of patients to ULT treatment. Automated feedback and risk stratification based on home monitored values can be a promising next step.
References
1. Doherty, M., Jenkins, W., Richardson, H., et al. (2018). 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. The Lancet, 392(10156), 1403-1412.
2. Riches, P. L., Alexander, D., Hauser, B., et al. (2022). Evaluation of supported self-management in gout (GoutSMART): a randomised controlled feasibility trial. The Lancet Rheumatology, 4(5), e320-e328.
3. Beard SM, von Scheele BG, Nuki G, Pearson IV. Cost-effectiveness of febuxostat in chronic gout. The European journal of health economics : HEPAC : health economics in prevention and care. 2014;15(5):453-63.
4. Hakkaart-van Roijen L, Peeters S, Kanters T. Dutch Guideline for Economic evaluations in Healthcare. Dutch Care Institute; 2024.
